Episode 44: Deep Listening with Danielle Ofri

 

Danielle Ofri:              

You know, she opened the door and was standing outside the room, but she didn’t let go of the doorknob yet. She said, “Excuse me, Doctor, can I ask you one more question?” I said, “Sure.” She said, “Do you think that the fact that all that it matters, that all these aches and pains are spots where my boyfriend shot me with a dart gun?”

Oscar Trimboli:            

Hi, I’m Oscar Trimboli, and this is the Deep Listening podcast series designed to move you from an unconscious listener to a deep and productive listener. Did you know you spend 55% of your day listening yet only 2% of us have had any listening training whatsoever? Frustration, misunderstanding, wasted time and opportunity along with creating poor relationships are some of the costs of not listening.

Oscar Trimboli:            

Each episode of the series is designed to provide you with practical, actionable, and impactful tips to move you through the five levels of listening. So I invite you to visit OscarTrimboli.com/facebook to learn about the five levels of listening and how others are making an impact beyond words.

Oscar Trimboli:            

In this episode of Deep Listening – Impact Beyond Words, we hear from Dr. Danielle Ofri on the cost of not listening in medicine. There were so many parallels with Dr. Michael Boyce from Episode 22 and the impact that the medical system has on patients when doctors aren’t present, engaged, and alert, when they’re not listening carefully. Danielle explains how the average doctor interrupts the patient less than 20 seconds into the consultation. This reminded me of the amazing interview in Episode 28 where we spoke to Vanessa in Japan who visited her doctor and was completely swamped and overwhelmed when she was told by her doctor that she had breast cancer, a diagnosis she was completely not expecting.

Testimonial:                

I remember when I was just told when I walked into the office, we need to get my test results and I didn’t have my husband with me and I was expecting it to be good news. Oh, it’s just this kind of benign lump, the biopsy’s come back and it’s all kind of … I had convinced myself that it was going to be fine, so I hadn’t actually prepared myself for anything other than “Oh, you know, it’s a benign lump,” and breast results doctor, the first … not the actual surgeon, he just said, “So, you’ve got cancer.” That was the first words out of her mouth. And I just went blank.

Oscar Trimboli:            

Danielle talks about this during the episode, so listen out for that. Danielle has written a wonderful book called What Patients Say and What Doctors Hear. This isn’t based only on her personal experience, but she’s undertaken extensive research across North America and many other locations to dig into the disease that creates the largest number of medical errors and malpractice suits — not listening to their patients.

Oscar Trimboli:            

This week, I was touched. I received an email from Patricia in the Netherlands who explained how she’s been using the five levels of deep Listening in training with health care professionals to work with people with autism. I haven’t met Patricia, but I’m honoured that the five levels of listening are being used all around the world, whether it’s the Netherlands, Germany, United Kingdom, Canada, the USA or New Zealand. There are many organisations integrating Deep Listening – Impact Beyond Words into what they do. To Patricia and the team of medical professionals in the Netherlands, thanks for having an impact beyond words. Now let’s listen to Danielle.

Danielle Ofri:              

It’s interesting because in the booklet I’ve just written about communication, the book What Patients Say, What Doctors Hear, I spend a lot of time, as you mentioned, looking at the downsides to miscommunication in terms of medical error, misdiagnosis, medical adherence, just actual dollar cost in the hospital, but the book I’m working on now on medical error, in some ways it feels like I’m almost writing the same book again because so many medical errors boiled down to communication. In fact, it’s probably the majority of medical errors that come to that.

Danielle Ofri:              

If you dissect down malpractice data from the US, more than half of the malpractice lawsuits come down to communication error. Of either speaking or listening or transmitting information, only a small minority are the actual true malpractice — you know, cut off the wrong leg, offering the wrong side kind of error.

Danielle Ofri:              

So just in that realm of medical error and cost, miscommunication is enormous, but there’s also a whole other side of communication in terms of the investment in the doctor-patient relationship. As an internist, I was in the clinic this morning and one of my patients is someone I’ve had, I’ve been seeing for, well probably eight or nine years, an older woman in a wheelchair who has cerebral palsy and we just uncovered, in this month, breast cancer. It’s very tragic and of course, I feel terrible. This sort of crept up on us and we didn’t catch it and suddenly just appeared.

Danielle Ofri:              

But I also feel so relieved that we have this whole history of eight or nine years together that now that we faced this new challenge, it’s so much easier because we already know each other well from so many visits of just chatting, catching up on life and things like that that may feel like small talk, but in fact lay down the groundwork so when the real big heavy things come up, you already have the scaffolding.

Oscar Trimboli:            

Are there some things that you do yourself when you’re seeing a patient for the first time on a really big, busy scheduled day that keeps you in the moment?

Danielle Ofri:              

Well, it’s always busy, but I do try to take a few minutes to prepare before the patient comes in so I’m not glancing at the chart when they walk in the door. Just today, the nurse said, “Can I bring Mrs Jones in?” I said, “Oh no, not yet. I haven’t looked at her chart yet,” because even though I could do it while she’s there, I feel less present. I’d rather have the patient wait a few more minutes outside and I do all the background work and then when they come in, I can then look at them and talk. What I try to do is see if I can spend even just the first minute or two fully engaged in the conversation without taking notes or writing, looking at the computer, and then once I’ve gained that sort of basic groundwork, then I may open up a chart and do some background work and do some writing. Otherwise, it’s so easy to get lost in the details of the computer.

Danielle Ofri:

Then the other thing I try to keep in mind is that although for me, this patient may be one of 10 patients I’m seeing this morning or 20 patients in the hospital ward, for that patient, they may have waited months for this visit or weeks or have been waiting all day in the hospital for the doctor to come in. For the patient, this is the one moment out of many others that’s so important, and try to keep that in mind. I remember when I’ve accompanied a parent or a grandparent to the doctor, how important it was for them and how meaningful it was, and so try to just keep in mind, for the patient, it’s a singular moment even for the doctor or nurse, it’s one of many in the day.

Oscar Trimboli:

This wasn’t always the case for you and maybe there was a tipping point where you were looking at charts as people were coming into the room and not maintaining eye contact. Was there a time or a patient you saw that was a point at which you said you had to change?

Danielle Ofri:              

I don’t think there was a particular patient, but I think, I would say going through illness with my own father and my husband’s parents gave me a little more of the view on the patient side of how important that visit is and how meaningful it is. My father passed away a few months ago, so we’ve had the last year or so of being just very involved on the medical side. Even in his last few days in the hospital, waiting around for the doctor and the doctor finally showed up, it was so important. Even if the doctor … once the doctor was rushed, I was so angry. This is our moment. We’ve waited all day for you to come by. I think it’s been a little more time on the patient side of things that really made me understand how important even a few minutes of presence really means.

Danielle Ofri:              

What I really noticed was the differing priorities. With my father, we were getting ready to bring him home and we were all set up, got him dressed and got that and got the ambulance to come and wheelchair, and the nurse came by and said, “Oh, his magnesium is low. He’s got to stay another day and get another IV replacement.” Of course, and his IV was taken out. I said, “This is crazy. I know as a physician that magnesium is not an emergency, he can go home.” “No, this is what the doctor said. The surgeons are now in the OR and they can’t be reached. It has to be done.”

Danielle Ofri:              

I was so angry that we had to get them undressed for another IV and it caused pain. The next morning, I got there at 6:00 in the morning and barricaded myself in the room and would not let them draw any more blood. I don’t care what the results are, he’s got to go home. The doctor kind of gave me, “Fine, fine,” said “Okay, fine. You know, if you refuse,” well you know, but I realised that you need an advocate, and that if I hadn’t been there, my father would’ve stayed even longer, and each time someone stays longer, an elderly person, another thing goes wrong. He never would’ve gone home.

Danielle Ofri:              

We got him home that day and he was able to spend his last few weeks at home in his own apartment, in his own bedroom with the window open. I was so grateful that we could have achieved that, but it was a really quite a fight. I had to buck the medical establishment and I could do so because as a physician, I knew what was going on and I recognise it. If I didn’t know that, it would’ve been so hard. So many patients … most people don’t have a doctor on hand in their family to do this sort of fighting or to get there at 6:00 in the morning.

Danielle Ofri:              

In some ways, the system is so stacked against the patient. The patient gets lost in the mess of all these different power struggles and these different hierarchies, and it can be so hard to fight your way out. It just gave me a sliver of insight to what hard work it is to be sick. Forget the part of actually really being sick, the logistics of being ill and navigating that, it seems so unfair that we burden patients who are already ill with everything else you have to figure it out and it just doesn’t seem right. So that was my big learning experience.

Oscar Trimboli:            

How would you quantify the cost of not listening inside hospitals today?

Danielle Ofri:

I think it’s an enormous, enormous cost. I’ll relay to you a clinical study from back in the 1960s, which my kids called the olden days, but it was a study that was looking at post-op pain for patients who’ve had abdominal surgery. If you’ve ever had abdominal surgery or know someone who has had it, you’ll know how painful it is when the anaesthesia wears off. The pain is so powerful, it usually requires very strong pain medication such as opiates, narcotic medications. These medications, of course, have a myriad of terrible side effects that range from nausea, vomiting, stomach upset, and constipation to addiction, respiratory suppression, and death. So minimising narcotic use is an important priority for everyone involved.

Danielle Ofri:                                     

This simple study took 200 patients who were getting abdominal surgery. On the night before, the anaesthetists went bed to bed and to discuss the surgery coming up as per usual, but for half the patients randomly selected, they added in a 20-minute discussion about post-op pain. There was no rocket science here. Just you know, about where the pain usually occurs, when it might come, how it’s caused by the clenching of the abdominal muscles, and here’s some exercises to relax your muscles and that doesn’t work, here’s the button to call the nurse and if the nurse comes, here’s what, what you might get. You get nothing brilliant.

Danielle Ofri:              

The next day the surgeons, who didn’t know which patient was in which group, operated and took care of the patients. I think from the perspective of today, it seems obvious. The patients with the extra discussion probably had less pain, but it was the magnitude of that difference that really made me pay attention. Those patients who had the extra 20-minute discussion needed half the amount of narcotics, maybe 50 percent less of these powerful pain medications, and frankly, as an internist, anything that reduces constipation gets a gold metal in my book.

Danielle Ofri:                                     

Beyond that, those patients were discharged in the hospital three days earlier. That’s three fewer days of hospital acquired infections, falls, blood clots, no urinary  problems, not to mention some $15,000 or $20,000 in today’s dollars. That’s amazing, all from a 20-minute discussion on the very basics of pain.

Danielle Ofri:              

If you just extrapolate that, and that’s one tiny aspect of medicine, but just imagine that on many more aspects of, how to take your medications? When did you follow up appointments? Simple things like that that get lost in the shuffle. I mean, when a patient is discharged from the hospital, so much is going on. They’re given a list of medication, a list of appointments and physical therapy and a CAT scan to go forward. All these things to do that if even 10 percent gets lost in the shuffle, that could add up to a readmission to the hospital because they forgot one or two key things in the big swell of things happening.

Oscar Trimboli:            

Nearly $15,000 to $20,000 per day, and if they’re getting discharged earlier, the savings must be enormous. The reduction in infection that you mentioned, quite staggering to me as someone who doesn’t participate in those systems. One of the stories that reminded me of when we interviewed Vanessa Oshima out of Japan. She was a market researcher for Coca Cola at the time, she was diagnosed with breast cancer and one of the things she mentioned is the minute the word “cancer” was mentioned by the doctor, she shut down. Her listening stopped and she couldn’t hear any other words the doctor said from that point on. She said, ” Although I’m sure it was really important,” the minute the word cancer was mentioned, she moved to another place. Danielle, is there anything that you do to help the patient listen to you? Anything you do deliberately to ensure the patients heard what you’ve said?

Danielle Ofri:              

Well, I typically start by asking a patient what they understand thus far about their condition. Particularly when you’re bound to unload something like a cancer, something heavy like that, it is very important to see what the patient is thinking because if they’re thinking they’re having a stroke and you’re about to tell them about cancer, it’s very important to know that first of all, to be sure that they’re not having a stroke, but to help clear up misconceptions.

Danielle Ofri:              

I also ask patients, “How much detail do you want to know?” Not everyone wants every nitty gritty, and I think sometimes in the name of patient autonomy, we unloaded every last detail on the patient. We say, “Okay, now you decide, right?” Patient autonomy and that’s personal autonomy that for some patients can be overwhelming and there are some patients who will say, “I don’t want all the details. Just give me the basics and tell my adult child or tell my parent or my sibling the details.” I can respect that. I want to give them the opportunity before I unload that on Sunday. Some patient say, “I want to know everything.”

Danielle Ofri:              

Having a sense of where they’re coming from with their knowledge base, how much they want to know, so that’s usually my starting point. Then I will be honest about the information and then I’ll make sure that before I told them the diagnosis that I’ve done my homework and I have the plan ready. For example, the patient I mentioned who I saw today, who had a new cancer diagnosis. I got the letter, I knew it was cancer, but I didn’t call her. I waited a day or two because I wanted to get the entire treatment plan lined up. So when she said, “Well what do we do now?” I then said, “Okay, here is the plan.” Because if I called her and then had no answers for her questions, I think it will leave things more confusing and more disturbing then she’d have to live with this information and no roadmap. So I try to take the time, if it’s possible, to get my ducks in place. Okay, what are the statistics? What is the plan, what’s the treatment and what are the side effects? When they have questions I can answer them. Then I make sure we go back at the end because I realised, as you mentioned with this other person you interviewed, that once the word cancer or stroke or big things come out, people miss a lot. So I go back at the end, review the things, I write down the key points. I’ll also say, “Is there someone else you’d like me to talk to?” Maybe they didn’t have a chance to bring in a spouse or a friend. If they give me permission, I’ll then call this family member or friend and give them the key points that can help reinforce that. Then I follow up with another phone call. I check in a few days later. You know, “How are you doing?” and we talk about a lot, you know, “Do you have any more questions or anything didn’t make sense?” Because things often come up later and you need a second chance to revisit these very heavy diagnosis.

Testimonial:                

My communication has been impacted in significant ways since reading this book. I’ve had my awareness raised. I’ve always seen myself as a strong communicator, but I can already feel the difference. I listen more carefully, I feel more attuned, and my relationships are richer for it. This is a book that you can read in about an hour, but the value is not in reading it. The value is in studying it, pondering it, and practising it, and if you do, the results will be instantaneous.

Oscar Timboli:             

What an extraordinary example of empathy and true patient-centric medicine. I sense of a lot of doctors would want to basically get through the appointment and move on to the next one, but the care you took to wait a day because that was the right thing for the patient — not necessarily for you — probably something that isn’t taught in medical school. Can you think back to the time you were studying and what’s your one wish, that you would have been taught about listening during your time studying as a doctor?

Danielle Ofri:                                     

I think when I look back to my best lessons, although there were fewer than the others, was the times we sat with an experienced clinician and watched them just talk with the patient. I can remember my first or second patient interviews with such clarity. I forgot everything else my first year in medical school, but sitting with a doctor who took the time … I even remember, as a first year medical student and the psychiatric ward intervened as a group with a patient and then the doctor called us out after we met her and said, “You know, I think he saw you as very naive and kind of told you what you wanted to hear. Let’s go back and talk to him again and see if we can push a bit below the surface.” With her encouragement, she prompted the conversation a bit, she got us to get below, whereas I would have walked away from the first conversation thinking that was it, I’ve gotten the story. But she was able to pick up that it wasn’t a very authentic conversation and the patient was withholding for whatever reasons, and took the time to go back and dig deeper, and there was much more below that.

Danielle Ofri:                                     

I’ve forgotten just about everything else my first year medical school, but I’ve never forgotten that approach and what she got out of taking the time. She listened deeply enough to catch that we

weren’t completely done yet.

Oscar Trimboli:            

So she noticed something that you didn’t and she was listening differently. What do you think she heard that you weren’t hearing at that time?

Danielle Ofri:                                     

I think what she heard as an experienced psychiatrist was that he was too smooth, for the sense of what she knew of his condition. His responses were very packed and very easy, and they were the perfect responses, because he seemed to know what we wanted to hear and he filled that right in. Of course we were anxious to hear that, so we checked our boxes off in our head, but she saw the mismatch in that it was too perfect for his known diagnoses. She suspected that, that there was more to be seen underneath. From that I took the idea of, you know, the first conversation is just the entree and not always, but very often we can circle back and there’s more. So maybe I’ll say the end, “Is there anything else you think you want to add?” Or, here’s what I’ve gotten so far. What am I missing?”

Danielle Ofri:              

Then sometimes if I have a student with them, I’d say, “You know what, we’ve got a student today. You as an experienced patient, what’s a lesson you could give to them to how to be a better doctor?” Patients always have things to say to that and always very telling because it’ll be based on their experiences. So they may talk about getting a diagnosis poorly given or not getting the medications correctly. Then I’ll know, “Oh, that’s probably an important point for this patient because they brought that up now.”

Oscar Trimboli:                                   

A really powerful example of level four listening to explore what’s unsaid in your questions there in your own work and your own practise. Is there a story that comes to mind where you explored? Is there anything else, and you were surprised and the patient diagnosis took a different turn?

Danielle Ofri:              

Yeah, there was a patient … well it was really her initiative more than mine, but a young woman, she was wearing a baseball cap and she came in just complaining about a fungal rash in her scalp. Very simple and easy to treat. Then she talked, she mentioned various aches and pains in different parts of her body and things that didn’t add up to any particular syndrome. You know, it was an elbow, it was a knee, it was the side of her thigh. I examined her, she was perfectly healthy, and I said, “Yeah, just sort of the aches and pains of life,” and you know, “I’ll see you next year,” kind of thing. Then we said goodbye. She walked out, I went back to the computer and started writing. Then she was out in the hallway, she opened the door and was standing outside the room but you didn’t let go of the door knob yet.

Danielle Ofri:                                     

She said, “Excuse me, Doctor, can I ask you one more question?” I said, “Sure.” She said, “Do you think that the fact that all that it matters, that all these aches and pains are spots where my boyfriend shot me with a dart gun?”

Danielle Ofri:

I realised that of course it was domestic violence underneath all of this and I had missed it, and I really should have, you know, when someone has disparate aches and pains that don’t add up, you really do want to query about intimate partner violence. But I hadn’t, I was really staying with the surface, but she luckily, she held onto the doorknob and I feel was courageous enough to stay holding on and to push one more time to get me to hear. Luckily, I caught it, because we know that these are people who become murder statistics so easily in these situations, and I was so grateful that she did this and reminded me that I’ve got to always be careful to make sure nothing else it is going on underneath.

Oscar Trimboli:            

There were two paths that were possible. One is kind of very difficult to even imagine. Thanks for taking that extra time with that patient. I’m sure it made a lifetime of difference to her.

Danielle Ofri:                                     

The other thing that I find, because the medical interview these days is often conducted with a computer between the doctor and patient, usually inhibits, I think, good conversation and good listening. The physical exam is now the safety valve for listening and conversing, and that once we moved to the exam table, now we’re communicating without the computer between us and we’re also touching and touching adds a kind of intimacy. It’s not in romantic but it’s an intimacy nevertheless, and any intimacy changes the dynamics of conversation and countless times, that’s when a patient will say what’s on their mind. I look at it as my second chance at good conversation.

Oscar Trimboli:            

Compared to when you started off in practise, have you moved when you do the physical examination, knowing that there is this new technology in between the patient and yourself?

Danielle Ofri:              

Well, I didn’t try to get to it sooner. I mean I usually have our conversation first and then do the physical exam, but often I leave the physical exam to the very end because it’s less important diagnostically. But now I try to do it sooner because it’s part of my … I see it as part of the history taking and we’re sort of continuing the conversation. As we’re touching and as we’re away from technology … I mean there are so few minutes, moments in life of communication without a technology interfering. It’s quite rare, and I think in that manner very unique and special and we should really take advantage of these moments to communicate with nothing in the way at all. It really does create a different sort of connection.

Oscar Trimboli:            

Thinking about what this conversation will be prompting for those listening, and when I think about them, they’re all telling me they’re really, really busy. Having a luxury to listen for a long period of time is just not something that they’ve got time to do. What advice would you have for them?

Danielle Ofri:                                     

I sympathise because we’re all in the same boat, but the research shows that doctors cut patients off within 8 to 10 seconds. Very short amount of time, and there’s all kinds of problems with that and medical errors. I wondered how long patients would talk if we didn’t interrupt and cut them off. In fact, the TV show that … patients usually only talk for about 90 seconds before they come to a natural halt. Well, you know, 90 seconds, I can do that as a listener. I can let them talk. When I tried that, it is true. Most patients will stop within a minute or so, so if you give someone even just one minute of what I like to call full frontal listening — no interruptions, no computers, maybe just taking a note or two and just nodding, the patient or whoever you’re talking to, A, we’ll give you the most important information; and B, will feel listened to, and that alone is worth so much.

Danielle Ofri:                                     

In my patients, the ones who tend to be the chronic complainers, if I let them talk, they too come to a natural end. Maybe a little more than 90 seconds, but they also within a few minutes will come to an end and once I let them do that, they’re much less anxious. They don’t come in little, “Oh, I forgot 16 more things to tell you.” Lowering their anxiety level and engaging their trust with those one or two minutes of full frontal listening is incredibly valuable and it’s an investment in your future relationship.

Danielle Ofri:                                     

I advise people in any walk of life, just try that. Just give one minute of listening and you’ll see that you don’t need to take an hour. I mean an hour’s great if you got it, but often we don’t. Try that minute.

Danielle Ofri:              

What I do in my circumstance for the patient, we’ll do a minute of listening. Then I’ll say something like, “You know, I don’t want to miss what you’re saying. Would you mind if I took notes while you speak?” Then I’ll get to the computer. That way have pulled it in, but I’ve also still given them that full focus listening.

Oscar Trimboli:                                   

First off, a big thank you to the 1,464 people who are undertook the Deep Listening survey. The questions were designed to understand what frustrates you about what other people do when they’re not listening, understand a little bit more what you struggle with when it comes to listening, and ultimately what’s the one thing you want to do to improve your listening?

Oscar Trimboli:                                   

Watch this space. We’re going to use that information to help build out and provide more information that’s more practical so that you can apply it to become a deep listener. Listening to Danielle as an intern and how her supervising doctor taught her that patients sometimes are to provide perfect answers and if you’re not listening deeply enough, you may miss it. How many people are you listening to right now who are providing the perfect response to your questions, immediately allowing you to tick the listening box rather than being curious and listening a little bit more?

Oscar Trimboli:            

I’m completely fascinated by many of the insights Danielle provided, especially when it came to helping out her patients. Here’s some questions I loved and Danielle posed all these while exploring Level Four in How to Listen. She was listening for what was unsaid.

Oscar Trimboli:                                   

Take a note of these questions and see if you can use them yourself. What do you understand now about your condition? How much detail do you want to know? Is there someone else you’d like me to talk to? Is there anything you would like to add? Here’s what I’ve heard so far. What have I missed? Is there anything else you would like to ask me? What I love about all these questions is practically, they can be applied to any conversation.

Oscar Trimboli:            

I love this term that she used — full frontal listening. Intention was dripping from every syllable when she said just take the time to provide a one minute of full frontal listening, not an hour, and you’ll transform your own understanding as well as theirs.

Oscar Trimboli:            

Thinking about what I’m going to apply from this interview, well, I make a lot of default assumptions in everyday conversation, so I’m going to pause a little bit longer and think about listening to what they haven’t said, thinking beyond their perfect response and trying to understand a little bit more in terms of full frontal listening. I wonder what you’ll apply from Danielle and today. Thanks for listening.